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Hepatic Neoplasms
Benign Liver
Biliary Neoplasms
Benign Biliary
Exocrine Pancreas
100
You are performing a laparoscopic liver resection for an isolated 1-cm HCC located in segment VI. The patient is a 60-year-old man with Child class A cirrhosis. After establishing pneumoperitoneum and dividing the triangular ligaments, what is a key step before proceeding with resection of the mass?
What is Perform intraoperative ultrasound.
100
A 58-year-old male has had multiple episodes of bleeding from esophageal varices in spite of prevention attempts, both pharmacologic and endoscopic. He has been reluctant to consider a portosystemic shunt because of concern that he might develop hepatic encephalopathy. His Child-Turcotte-Pugh (CTP) score is Class A. Which of the following procedures would be best for this patient?
What is Transjugular intrahepatic portosystemic shunt (TIPS)
100
A 68-year-old female undergoes a laparoscopic cholecystectomy for acute cholecystitis. Three days later, pathology reveals adenocarcinoma T1b invading the muscular layer, without perineural, lymphatic, or vascular invasion, and negative margins. What additional management would you recommend?
What is No further treatment necessary
100
A 50-year-old male with intermittent epigastric pain has an abdominal ultrasound showing a 7-mm gallbladder polyp with no gallstones. What is the next step in the management of this patient?
What is Follow gallbladder polyp with serial ultrasounds Asymptomatic gallbladder polyps less than 10 mm can be safety watched with serial ultrasounds to monitor growth
100
A 45-year-old male with prior history of repeated episodes of alcohol-induced acute pancreatitis presents with a one-month history of weight loss, epigastric pain and loose foul-smelling stools. Abdominal CT demonstrates pancreatic atrophy and calcifications without duct dilatation. What is the most appropriate management of his abdominal pain?
What is Administer tramadol. Pancreatic enzyme replacement, somatostatin analogues, and allopurinol have not been found to be effective in managing the pain of chronic pancreatitis. Therapeutic endoscopy is only of benefit in the setting of a main pancreatic duct stricture, head of the pancreas ductal stones, and symptomatic pseudocyst. Tramadol has been found to be as effective as opioids without the risk tolerance or dependence.
200
A 56-year-old male with a known history of alcohol-related Childs B cirrhosis presents with complaints of RUQ abdominal pain and weight loss. Clinical exam is notable for mild abdominal distension. Contrast-enhanced CT scan demonstrates a 1.5-cm lesion in the segment 5 of the liver. In the arterial phase, there is homogenous intense enhancement than the surrounding liver and in the portal venous phase there is washout of the contrast (read as highly suggestive of hepatocellular carcinoma). His only liver function abnormality is a total bilirubin of 2.1 mg/dL. What is the next best step in the management of his liver lesion?
What is Contrast-enhanced MRI
200
A 45-year-old woman comes to the emergency room after vomiting a cup of bright red blood 2 hours ago. Her vital signs are normal. She has a history of hepatic cirrhosis from chronic hepatitis B infection. She has had one previous episode of upper gastroesophageal bleeding 5 years ago. Her only medication is Interferon alfa-2b. Hemoglobin is 10 and INR is 1.0. She is admitted to the hospital, and upper endoscopy is performed. There are multiple varices present at the gastroesophageal junction with bruising noted over one of them. No active bleeding is present. In addition to admitting the patient to the hospital and infusing intravenous fluids, which of the following is the best management of this patient?
What is Begin infusion of octreotide.
200
A 77-year-old woman presents with suspected acute cholecystitis and a 5-kg weight loss over one month. A RUQ US showed asymmetrical thickening of the gallbladder wall and a “polyp” in the fundus. Upon insertion of the laparoscope an extremely hard gallbladder is seen and gallbladder cancer is suspected. How should you proceed in this situation?
What is Document all relevant findings, abandon the procedure, and refer the patient to a center with available expertise. The appropriate treatment consists of radical cholecystectomy including segment IVB and V and lymphadenectomy and extended hepatic or biliary resection as necessary to obtain negative margin.
200
A 45-year-old female presents to the emergency department with fever, jaundice, and altered mental status. She had elective laparoscopic cholecystectomy one week prior and has complained of abdominal pain since. What is the likely diagnosis?
What is Retained common bile duct stone
200
A 69-year-old female comes to the office with complaints of residual epigastric pain following an episode of acute pancreatitis 4 weeks ago. CT scan shows a pancreatic pseudocyst, 4cm in the tail of the pancreas. What is the next step in management?
What is Observation The patient has only had symptoms for 4 weeks.Minimum wait time for intervention on a pseudocyst is 6 weeks. This is to allow for the wall of the pseudocyst to mature, and minimize the chance of leakage from any drainage procedure (cyst-gastrostomy or cyst-jejunostomy). Catheter drainage of the pseudocyst is contraindicated, as it will result in a pancreatico-cutaneous fistula.
300
A 53-year-old man presents with vague abdominal pain for the past two months. He has a history of cirrhosis secondary to hepatitis C. His vital signs are normal. His abdomen is soft and minimally tender in the right upper quadrant. There is no encephalopathy or ascites. Albumin is 3.6 mg/dL, total bilirubin is 1.1 mg/dL, and alpha fetoprotein is 800 ng/mL. A CT scan shows a cirrhotic liver with a 3 cm mass just to the right of the falciform ligament. Which of the following would be required to resect this mass?
What is Left hepatic lobectomy
300
A 55-year-old male with Child C cirrhosis comes to the office because of fluid that has been staining his shirt over his abdomen for the past 2 weeks. On examination, his vital signs are normal. His abdomen is distended with a palpable fluid wave. There is a 5-cm umbilical defect with a hernia protruding 7 cm out from the abdominal wall, and a small amount of weeping clear yellow fluid. There is no erythema or tenderness of the abdominal wall. In addition to maximizing control of the patient’s ascites, which of the following is the best management of this patient’s hernia?
What is Schedule an umbilical hernia repair within the next week.
300
A 55-year-old woman with controlled hypertension and type II diabetes presents with painless jaundice and a 6-kg weight loss over three months. Workup reveals obstruction of the distal common bile duct with no evidence of metastatic disease. ERCP with stent placement and bile duct brushings show cholangiocarcinoma. What is the most appropriate treatment?
What is Pancreaticoduodenectomy The most appropriate treatment for this patient is a Whipple procedure. Palliative care may be appropriate for patients at high risk for operation or who do not want an operation. Radiation therapy does not improve survival or resectability in this situation. The other choices are not appropriate.
300
A 46-year-old female with 6 months of epigastric abdominal pain that is associated with fatty foods presents to the office for evaluation after an ultrasound of her gallbladder demonstrated an 8-mm gallbladder polyp and numerous gallstones; the reminder of the gallbladder and liver appear normal on ultrasound. Her liver function tests are within normal limits. What is the next step in management?
What is Laparoscopic cholecystectomy Symptomatic cholelithiasis in addition to a gallbladder polyp are an indication for cholecystectomy, regardless of manner. Laparoscopic cholecystectomy is the current gold standard for cholecystectomy.
300
A 60-year-old man presents to his gastroenterologist with jaundice and occasional abdominal pain. He has had multiple hospitalizations for abdominal pain and elevated lipase. An endoscopic ultrasound is performed of the pancreas revealing diffuse inflammation with a possible mass-like appearance of the head of the pancreas. A biopsy is performed revealing diffuse lymphocytic infiltration. What is the next step in treatment?
What is Corticosteroid treatment
400
A 57-year-old man with Hepatitis C and cirrhosis presents to the office for evaluation of RUQ pain. He has lost about 10 lbs. over the course of 6 months. He is noted to have RUQ tenderness. Ultrasound shows a large mass measuring 8 cm in the right hepatic lobe. There are no gallstones. You order serum alpha-fetoprotein which comes back elevated. You then decide to order a contrast-enhanced CT. Which findings would you likely see?
What is Rapidly enhancing, well-circumscribed mass with complete pseudocapsule
400
A 55-year-old woman with polycythemia vera presents with mild right upper quadrant abdominal pain, ascites, mild leg edema, and hepatomegaly. Serum transaminases are three times normal. A technetium sulfur colloid liver scan shows poor uptake in most of the liver with increased uptake in an enlarged segment 1 of the liver. It is most likely that this patient has
What is hepatic vein thrombosis
400
A 62-year-old male presents with progressive painless jaundice and weight loss over 3 months. CT reveals a hilar mass with extension into the right hepatic duct. CA 19-9 is 140 U/ml. A provisional diagnosis of Bismuth Type IIIA hilar cholangiocarcinoma is made. Which among the following features precludes the patient from having a curative resection?
What is Tumor extension into segment 3 duct Bilobar intrahepatic metastases and any extrahepatic disease are contraindications to resection, as is the involvement of bilateral secondary biliary radicals. Other contraindications to resection include encasement of the main portal vein, bilateral hepatic lobar artery involvement, and lobar atrophy with involvement of the contralateral portal vein or biliary radicals.
400
A 63-year-old obese female presents with RUQ abdominal tenderness with nausea and vomiting for 2 days. She is febrile (101.8ºF) and her pulse 116 bpm. Significant labs are: WBC 17,000/mcL, total bilirubin 3.3 mg/dL, transaminases 1.5 x normal. CT with IV contrast shows a distended gallbladder with wall thickening and pericholecystic fluid. Cardiac evaluation shows an NSTEMI. What is the appropriate intervention?
What is Percutaneous cholecystostomy
400
A 28-year-old woman presents to her gastroenterologist with recurrent pancreatitis. She denies alcohol abuse and imaging reveals a normal gallbladder without cholelithiasis. MRCP is performed showing two distinct pancreatic ductal systems without communication between the two and slight dilation of the main duct along the length of the pancreas. The cause of this patient’s pancreatitis is likely due to
What is stenosis of the lesser papilla
500
A patient is 3 years status post–left hemicolectomy for a T3N1M0 colon adenocarcinoma and now presents with an elevated carcinoembryonic antigen (CEA). Computed tomography (CT) reveals a 4-cm hypodense lesion in segment 5 of the liver. In addition to consideration of systemic chemotherapy, which of the following should be recommended to the patient?
What is Segmentectomy
500
A 38-year-old woman had a partial right hepatic resection (segments 5 & 8) for a symptomatic hepatic adenoma. Three days later, she develops vomiting and ileus with increasing abdominal pain. There are no signs of surgical site infection. Lab values are: serum bilirubin, 3.8 mg/mL; white blood cell count, 13,500; Hct, 27. Vital signs are normal. The next step in management should be
What is imino diacetic acid (IDA) scan
500
A 59-year-old woman has an incidental gallbladder cancer diagnosed following elective laparoscopic cholecystectomy. Further workup reveals a stage 2 tumor. What is not an essential component of resection for stage 2 cancer of the gallbladder?
What is Port site excision
500
What is the most common site of benign biliary duct tumors?
What is periampullary region.
500
A 48-year-old woman with chronic pancreatitis and longstanding epigastric pain undergoes a CT scan of the abdomen that reveals an inflammatory mass with calcifications in the pancreatic head with a 2-cm pseudocyst, atrophic body and tail. EUS-guided biopsy of the head mass reveals inflammatory cells with no evidence of malignancy. CA 19-9 is 8U/ml. What is the best surgical strategy for the patient?
What is Duodenum-preserving pancreatic head resection (Beger)